Hemangiomas - Life Cycle

Hemangiomas pass through two stages in their life cycle: growth (proliferation) and
shrinkage (involution). Initially, the hemangioma grows, during the first
year of your baby's life. During this period, most superficial hemangiomas
become raised, shiny, and bright red in color. The hemangioma is firm,
warm to the touch and can swell when the baby is upset or sick. For most
hemangiomas, two growth cycles exist: the Primary Growth Cycle, lasting
from birth to two months of age, and the Secondary Growth Cycle, starting
around the fourth month and lasting for six to eight weeks.

Between the tenth and twelfth month, most hemangiomas stop growing, and the lesion
begins to shrink and fade. This process may take anywhere from two to
twelve years. Some will completely disappear, while others will not and
may require corrective surgery. Hemangiomas are the only vascular lesion
to go through this process of growing and then shrinking, and a lesion
that continues to grow with the child, beyond one year of age, is most
likely a vascular malformation, not a hemangioma. Also, a lesion that
is present at birth but does not begin to grow for several years is undoubtedly
a vascular malformation.

There are some tangible signs the lesion is in the involution phase. You know
it is shrinking when:

     - it's less tender (painful) and softer to the touch

     - the hemangioma doesn't get bigger when your child cries

     - a superficial hemangioma turns from a bright red to a dark, deep maroonish
       color, or to a grayish hue is evident

Hemangiomas may exhibit two types of regression cycles: a Rapid Regression
Cycle and a Slow Regression Cycle. Half of all hemangiomas are slow regressors.
Usually, if no change in size is seen by age three to four, you can consider
the hemangioma a slow regressor. Certain sites such as the lower lip and
the nose are believed to be sites in which regression is slow. Active
intervention is usually necessary. Knowing whether the type of regression
is slow or rapid is significant to the treatment of the remaining lesion,
since we are more likely to treat a slowly regressing hemangioma.

By five years of age, 50 percent of hemangiomas complete their involution
phase. By seven years of age, this figure has reached 70 percent. The
remaining cases take three to five years longer to complete their involution
process. Once the involution (shrinking) phase begins, a superficial hemangioma
fades to a dull maroon hue and becomes much softer to the touch. Later,
it becomes gray and mottled from the center of the lesion outward. Over
a period of years, the gray gradually turns to a very light flesh color.
A deep hemangioma, on the other hand, does not exhibit a color change,
but becomes softer as the involution process proceeds.

A large superficial hemangioma, upon complete regression, may have a wrinkled
crepe-paper-like appearance (epidermal atrophy) not unlike an extensive
stretch mark. The problem comes from the loss of collagen and elastin.
Collagen is the substance that gives skin both its thickness and smooth
appearance and elastin its elasticity. The growth of the hemangioma results
in the destruction of both collagen and elastin. When the lesion shrinks,
there is no collagen to support the skin and fill in the gap; the skin
is therefore loose and wrinkled. The color of the affected skin may also
be slightly lighter than the child's skin tone. Superficial hemangiomas
may also leave red veins (telangiectasia). The excess skin can be removed
surgically or resurfaced with a laser, and the veins removed with laser
therapy. A CO2 or an ER:YAG laser is used for resurfacing and a pulsed
die laser or a KTP laser is used to treat telangiectasia.

If the hemangioma ulcerated, there will always be a white scar where the
ulceration occurred. There is no way to prevent this scarring, but it
can be treated with corrective surgery or skin resurfacing.

Hemangiomas at the tip of the nose tend to be disfiguring and slow regressors. This
lesion pushes the nasal tip cartilages apart and this splaying effect
may remain even after involution is completed. Corrective surgery works
well to repair this problem.

Deep hemangiomas may leave a contour type deformity or a lumpy area under the
skin made up of deposits of fibro-fatty tissue. Surgical removal eliminates
this problem.

Compound hemangiomas leave varying degrees of both the superficial and deep lesions:
crepe-like excess skin, red veins, and fibro-fatty tissue. All these problems
can be treated.